Print Inspection: WFD8

Based on interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of the admission records for Resident 1 indicated a move-in date of 12/13/21.

A review of the "30-Day Evaluation/Assessment" for Resident 1 indicated an assessment was completed approximately 53 days after move-in on 02/05/22. Resident 1's service plan was then updated on 02/18/22.

The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 07/08/24.

The facility failed to review the initial service plan within 30 days of move-in to ensure that any changes made to the plan accurately reflect the resident's needs and preferences.

Verbal Plan of Correction: The facility created a spreadsheet that is shared with management to track resident's due dates and their new system Point Click Care "triggers" due dates for service plans. These two systems provided a "double check system."

Based on observation, interview, and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors.

The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents.

A review of the posted staffing plan (undated) indicated the following:

* Adams House - 6am-6pm: 1 Universal Worker

* Hood House - 6am-6pm: 1 UW

* Float 6am-6pm: 1 UW

* Adams House - 6pm-6am: 1 UW

* Hood House - 6pm-6am: 1 UW

*Campus Float: 6pm-6am: 1 UW

In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following:

* The facility had an approved waiver for a "float" between buildings.

* The "float" was counted towards the staffing hours.

On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submitted via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests.

In an interview, Witness 3 (Operations and Policy Analyst) stated the facility's "float" did not count towards the facility's required staffing hours.

On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following:

* There was one UW in each house.

* No "float" staff were observed.

In an interview, Resident 5 stated the following:

* Only one staff member worked during the day.

* Resident 3 required two staff members for transfers and incontinent care.

* Wait times for help were often 30 minutes.

A review of Resident 3's service plan, dated 06/25/24, stated that resident required the assistance of four staff members to evacuate the building in the event of an emergency.

In an interview, Witness 1 (Outside Provider) stated the following:

* It was hard to find staff.

* Staff worked "between buildings."

* S/He was instructed to call a phone number to request staff assistance.

During the interview with Witness 1 at 11:28am, an unsampled resident wandered into Resident 2's room. The unsampled resident required redirection, which was done by the Compliance Specialist. Witness 1 stated s/he often had to redirect that unsampled resident because staff were hard to find.

In an interview, Witness 2 (Outside Provider) stated the following:

* It was hard to find staff.

* Only one staff person worked in each building.

* S/He was hired due to lack of staff available to care for Resident 3.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

Verbal Plan of Correction: Management will talk with the owner about the need for more staff and work to hire more staff.

Based on observation, interview and record review, conducted during a site visit on 07/08/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to:

CS observed the facility consisted of two separate, distinct buildings referred to as "Adams House" and "Hood House" with resident apartments on two separate floors.

The facility's resident roster, dated 07/08/24, indicated the facility was home to 23 residents.

In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the facility used the ODHS Acuity Based Staffing Tool and employed Universal Workers (UW) who worked 12 hour shifts.

A review of the posted staffing plan (undated) indicated the following:

* Adams House - 6am-6pm: 1 Universal Worker

* Hood House - 6am-6pm: 1 UW

* Float 6am-6pm: 1 UW

* Adams House - 6pm-6am: 1 UW

* Hood House - 6pm-6am: 1 UW

*Campus Float: 6pm-6am: 1 UW

In an interview, Staff 1 (Campus Director) and Staff 2 (Administrator) stated the following:

* The facility had an approved waiver for a "float" between buildings.

* The "float" was counted towards the staffing hours.

On 07/08/24 at 4:00pm, the CS requested a copy of the approved waiver from Staff 1 and a second request was submited via email on 07/10/24 at 10:46am to Staff 5 (CEO). The facility was unable to provide evidence of an approved waiver after repeated requests.

A review of the facility's Acuity Based Stafffing Tool (ABST) indicated the following:

* All residents were entered into the tool.

* The tool generated a staffing plan.

* The total hours of care needed was 23.92 hours.

* Five residents' profiles had not been updated in the last quarter.

On 07/08/24, throughout the site visit, the Compliance Specialist (CS) observed the following:

* There was one UW in each house.

* No "float" staff were observed.

* At 11:30am, a resident wandered into Resident 2's apartment. CS redirected the resident.

* At 11:37am, the CS observed Staff 3 (UW) was sitting at the kitchen table located on the upper floor. There was no staff available on the lower floor to supervise or rediect the resident who wandered into Resident 2's apartment.

In an interview at 11:30am, Witness 1 (Outside Provider) stated s/he had to redirect a male resident out of a female resident's room multiple times because it was difficult to find staff.

In an interview, Resident 5 stated wait times for help were often 30 minutes.

In an interview, Witness 2 (Outside Provider) stated the following:

* It was hard to find staff.

* On the morning of 07/08/24, s/he was unable to find staff.

* A private caregiver was hired because of a lack of staff and lack of care for Resident 3.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 07/08/24.

The facility failed to fully implement an Acuity Based Staffing Tool.